• John Deacon

WCJC #8, PG with NPWT and STSG

Surgical treatment of pyoderma gangrenosum with negative pressure wound therapy and skin grafting, including xenografts - personal experience and comprehensive review on 161 cases

Klaus Eisendle, Tobias Thuile, Jenny Deluca, Maria Pichler

Advances in Wound Care, DOI: 10.1089/wound.2020.1160

I don’t know about you, but pyoderma gangrenosum (PG) is one of the most challenging diagnoses that I treat. The wounds are painful, debilitating, and take months and months, sometimes years, to heal. The wounds look like they are begging to be debrided and surgically managed, but the risk of pathergy shies most, including myself, away from any treatment that may cause trauma to the wounds.

Therefore, I was intrigued when I came across this article discussing the use of negative pressure wound therapy (NPWT) and split-thickness skin grafting (STSG) in patients with PG.

For this study, a broad literature search for terms that included PG, skin graft, skin transplantation, negative pressure wound therapy, and vacuum therapy was performed. A total of 217 papers were identified up until December 2019. After identifying the articles with adequate data, a total of 101 remained for analysis.

At the author’s institution, since December 2011, all consecutive patients with PG, a total of 23, were treated with NPWT and STSG. All patients were hospitalized before surgical intervention and treated with 0.5-1 mg/kg of (methyl) prednisolone daily as well as further immunosuppressive or immunomodulatory therapy. Twenty of the 23 were treated with NPWT before surgical intervention. The STSGs were fixed in place with NPWT for 3-5 days. All patients received prophylactic antibiotics and low molecular weight heparin while undergoing surgical management.

The results of the literature review, including the author’s series, reported on 161 patients with 115 (72%) being female. There were 113 (71%) on the lower extremities. STSG alone was performed on 59 (37%) patients. STSG with NPWT was used in 41 (26%) of patients. STSG with hyperbaric oxygen therapy, flap, dermal substitutes, or xenografts in 11 (7%) of patients. NPWT was used alone in 22 (14%) of patients. NPWT with flaps, punch grafts, dermal substitutes, or xenografts in 7 (4%) of patients. NPWT with other forms of grafting in 21 (13%) of patients.

Systemic immunosuppression was mainly corticosteroids, used in 156 (98%) of patients. A single immunosuppressive drug was used in 41 (26%) patients, and additional immunosuppressive drugs were used in 38 (24%) patients. Immunosuppressive drugs included cyclosporine, dapsone, infliximab, adalimumab, mycophenolate mofetil, IV immunoglobulins, azathioprine, and pentoxifylline.

Treatment was successful in 139 (86%) cases with 17 (11%) having at least one recurrence. Two patients died of sepsis. No case of pathergy was observed at the site of PG or the donor sites.

For the author’s personal experience with 23 patients, the disease duration before treatment averaged 5.5 months. NPWT was started on day one of hospitalization. Systemic immunosuppression was started simultaneously or a few days prior. Adequate pain medication was provided to maintain the NPWT. Nineteen patients were treated simultaneously with NPWT and STSG. Of these, 13 had complete graft take and healed within two weeks. The other six had 75-90% graft take and improved or healed on follow up. Four patients had a minor recurrence that was successfully retreated. All donor sites healed without complication.

Of the patients treated with NPWT alone, the time for complete healing took one year for one patient, and one is still in treatment after four months.

Two patients were treated with porcine xenograft with good results.

The author’s concluded that the treatment of PG with NPWT and STSG is safe if performed under adequate immunosuppression. They feel it could be considered first-line therapy in larger PG ulcers because it markedly improves healing time.

My interpretation:

This study is limited in being a literature review of non-randomized patients with a high risk of selection bias. Still, the fact that the authors shared their own experience treating all their consecutive patients without any patient showing pathergy is important to consider. The rapid healing in most of their patients treated with NPWT and STSG would indeed be paradigm-shifting if replicated elsewhere. Many of my patients take months to years to heal with significant pain and quality of life issues. Faster healing would make a big difference to these patients.

I work with dermatologists and plastic surgeons to treat these patients. I will be strongly considering this approach with my next PG patient. A randomized trial would be ideal, and hopefully, this article will prompt one to be performed.

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